Director and Chairman of the University Clinic Bonn, Former Professor of Gynaecology and Obstetrics, Former Fellow at Wissenschaftskolleg zu Berlin
Breaking the Wall in Global Maternal/Child Health. How Medicine and Politics Can Reduce the Scandalous Discrepancy between Low and High Income Countries
When the wall came down, I was in the delivery room of the University Hospital. Women had tears of joy in their eyes, realising that their babies were born on this historic day.
So, I had my very personal experience with falling- yesterday- but it was good in two respects. First, it was on the occasion with the Einstein Fellows- the young people; and then maybe I helped a little bit the one who fell on me going down these 15 steps together with him on my back.
Birth should be a moment of joy, but in the world there are more than 350,000 women dying every year from childbirth. Which means that every minute of this talk, one woman will die from a pregnancy related cause. This is only the mothers. There are seven million babies dying, either in utero, or stillbirth, or directly after birth. The main reason they die after birth is the maternal deaths or the maternal poor health, and therefore prevention of the death of a mother is the single most important intervention also for the health of a child.
This is where the wall comes in. The lifetime risk of a woman to die from a pregnancy-related cause in this world, in our world, ranges from one in seven to one in 47,000. This is not a wall between East and West; this is, of course, between North and South. So, here is the wall: if you are a mother in Niger, in Africa, your likelihood of dying from childbirth is one in seven. If you are in Ireland it is one in 50,000. This was the idea of Mr. Turner, to put these crosses on the seat- on every seventh seat- to make us feel what that really means, lifetime risk: one in seven.
So there is this enormous inequality. 99% of these maternal deaths are in low-income countries. But these are numbers. Behind the numbers, of course, there are the individual stories. This woman from Tanzania, “I am going to fetch a new baby. The journey is dangerous, and I might not return.” This is what she says to her children.
This child born in March in Sierra Leone, no measurements, life expectancy, especially because of the high new natal death rate: 39 years. The same month on the 11th of March, this child in Germany, female, life expectancy: 82 years. It is an enormous wall, and this has been recognised by politics, especially lately.
Ban Ki-Moon, last month: “We know we can save lives of women and children. 16 million women and children can be saved within 2015”. But in order to achieve that, to come close, we have to analyse in a scientific way: why do mothers die? What are the reasons?
In the high-income countries we have these reports like in the UK, and they are growing, even though the risk of dying in the UK from the ‘50s to now has been reduced from one in 1,500 to one in 30,000.
But if we look globally, we can identify the ideologies. It is these major four: severe bleeding (haemorrhage after birth), infection, eclampsia, and obstructed labour. I want to show that, again, these three or four major reasons- all of those could be prevented to a very high degree if we would learn properly from the successes in some countries and apply them to others.
Lets start with obstructed labour, meaning that a birth goes over many hours, sometimes days. Then there is so much pressure on the tissue that these women often develop the so-called fistulae, which means that they then have a connection between the vagina, the intestinal tract, maybe the bladder, they smell, they are often abandoned by their male partners, the families, and this is 100,000 women per year: 2 to 3 million in the world who have this problem, which is very difficult to operate.
Haemorrhage: it occurs everywhere, but in a setting where you have the drugs available, the transfusions where you can do the surgery; this can be dealt with. It has always been there. Remember the Taj Mahal was dedicated to a woman who had died from postpartum haemorrhage.
We know the reasons why this can be lethal. They are listed here. The 3 Ds: delayed transport, delayed diagnosis, delayed treatment. As we say, and in countries where these techniques are available, we know what we can do: certain types of sutures. This can be applied in low resource settings, using tamponades or just uterine compression, which any skilled health care worker can do if it was taught properly.
There is a drug, Misoprostol, that is so cheap that it really should be available all around the world. It has been shown, here in a randomised study by WHO that it really is as good as the much more expensive drugs that we use, but this drug is off label. The company never applied for its use. Why? Because it is too cheap. So we have a big international effort now to make this available anywhere. Off-label, by the way, means that all the burden of litigation is on the shoulders of the doctors.
So, FIGO, which is our international organisation of Obstetrics and Gynaecology, has made this now a preference, really to put our knowledge into action to prevent postpartum haemorrhage. FIGO is associated with all these national societies, so we can go through our colleagues in the various countries. One aim is that we want these drugs to become available, so that after the delivery of a baby it can be helped that the uterus contracts. We have dedicated a whole issue of our journal to this purpose, which is then widely distributed.
Pre-eclampsia/eclampsia, meaning: women develop high-blood pressure, protein in their urine. There we have the interesting example that a drug was identified, magnesium sulphate, to be really useful, but it turns out that years after WHO put it on their list of essential medicines, less than 60% of the nations were using it. We really have a problem of implementation.
ERITREIA was mentioned- what we learned in ERITREIA is that we not only need the skilled birth attendance, but we need the centres where women can be referred to if there is a real emergency. We succeeded in the Capital (? 20:36) to increase the birth rate in the main hospital from 2,000 to more than 10,000, because it was accepted by the population by certain measures we took involving the local authorities.
The standards are: skilled birth attendants and the essentials at the same time. WHO has very much concentrated on the skilled birth attendants. Why? Because you see here the correlation: every mark here represents one country. There is an absolute correlation between the number of maternal deaths and the lower the percentage is of skilled birth attendants. What that means is that there is somebody there, like in this case, who can help if the uterus doesn’t contract properly, but I think this is an example of what we learned along the way by doing the analysis properly. This is not enough; it needs those centres that have to be accessible.
So there are all kinds of barriers that we can identify: the poor resources, of course, the availability of things, but then all these social, cultural, and belief issues are very important.
Look here: this is an 11-year-old woman who might soon get pregnant. We know that the risk, if she is 15 to 19 of having these severe problems is twice as high, if she is 10 to 14 it is five times more likely. If we look in the world, has the rate of adolescent pregnancies gone down? It has not. Actually there was a little decrease, but if you see here between 2000 and 2007 in Sub-Saharan Africa, no real further reduction. So, we definitely have to get better. It has to do with the role of woman. It is probably not a long way for this woman who works in the street, maybe getting into prostitution into trafficking. It is probably correct what Fathalla, also a FIGO president once said. He said, “Women are not dying of diseases we cannot treat. They are dying, because some societies have not yet made up the decision that their lives are worth saving.”
So with this background: what can be done? What has been done? There was an initiative already in 1987 to reduce maternal mortality. But then Jeffry Sachs, from Harvard, made the calculation that from the $60 billion that were promised to Africa by countries, only $45 million were realised. You see here the promises and what really happens. The target of United Nations 0.7 of the Gross National Product- not reached by many countries- average 0.4; and you see Germany, unfortunately is quite failing on this.
So, Jeffry Sachs came up with these Millennium Development Goals. Very quickly, the first one is about poverty. There is some good progress- those who live on less than a dollar a day- the percentage is going down. The next one is to involve children in primary school. Schooling you see here: the progress is not so high; the current trend is more than 100 million school age children will not be in school in 2015, the target year for these Developmental Goals.
Gender equality: this is the ratio of girls to boys in primary and secondary school. You see we are grossly failing on that. If we now look at those two MDGs 4 and 5 that have to do with perinatal health, you see that the progress here is also very low. Neonatal mortality is ten times higher. This is in the direct period after birth. Infant mortality, first year of life, twelve times higher; under five years, fifteen times higher. Also there, very similar to the maternal situation, we know that this would be, could be, avoided. Sachs, who analysed that very carefully, has pointed out that in the high-income countries this neonatal mortality went down even before there were neonatal intensive care units by doing simple things that could be applied. Very often in countries there are philanthropic organisations who are very well intended, but don’t really do things properly.
MDG 5 is concerned with the maternal health. One of the outcome perimeters is the one I mentioned about the skilled health personnel. You see here it is increasing; there is progress, because we have learned this, but again, if you look at certain regions- Sub Saharan Africa, only from 40 to 41%. This still is not satisfying at all. Then 5B was introduced, and 5B are these perimeters, contraceptive prevalence, family planning; and antenatal care coverage: that means that women get a certain minimum of care during pregnancy. WHO has listed this. This is not very expensive. This is evidence-based pregnancy care. Again, we see that from 1990 it has increased from 55% to 75%; but still this recommended four visits is not present in many places.
Now, we need a recording of maternal deaths, not to increase bureaucracy, but because it helps us to identify the individual problems, and it certainly helped a lot in ERITREIA. Family planning is important, because 35% of the maternal deaths could be averted through better access. Gates has pointed out that if you improve the health in a society, population goes down, and contraception usage increased worldwide from 15 to 57%; but there are still 23% of women in the low-income countries who have more than five to eight children, which puts both the mothers and the children at risk. 72% of the poorest women have no access in Latin America and Sub Saharan Africa. It is of course even higher. So, we need more access to contraception service, and we need access to safe abortion. This issue has to be touched, and sometimes international organisations don’t do it. 68,000 maternal deaths due to unsafe abortion, and again, this wall. So, the Millennium Goals in 4 and 5 are far away.
This is what I want to conclude with. It shows that there are countries that have made significant progress. The range is from continent to continent. Thailand is doing very well. Sri Lanka is doing very well, and Malaysia. I think what the task is that we learn from these countries, that we introduce exactly what they have done to other countries. This is what Gates Foundation and others have recognised. This requires a scientific approach that has not been there. Thank you so much!